=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144524513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J GUNDERSHEIMER, OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2010
-----------------------------------------------------
Last Update Date | 12/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E TAYLOR ST STE 210
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-2881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-868-1135
-----------------------------------------------------
Fax | 903-891-0181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 E TAYLOR ST STE 210
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-2881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-868-1135
-----------------------------------------------------
Fax | 903-891-0181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JEROME E GUNDERSHEIMER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 903-868-1135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 3473TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------